Labor & Postpartum Complications Study Guide

1. Premature Rupture of Membranes (PROM)

⚠️ Critical Point

Yellow or cloudy amniotic fluid = INFECTION (chorioamnionitis). This is your #1 concern!

Assessment Tools

Test	Positive Result	What It Means
Nitrazine Test	Blue/Purple color	Alkaline pH (7.0-7.5) = Amniotic fluid
Ferning Test	Fern pattern under microscope	Confirms amniotic fluid
Visual Pooling	Fluid in vaginal vault	Direct visualization during speculum exam

1. Infection Prevention (PRIMARY CONCERN)

Limit vaginal exams - each exam increases infection risk by 10%
Monitor temperature q2-4h
Watch for uterine tenderness
Monitor fetal heart rate for tachycardia (>160 bpm)

2. Fetal Assessment

NST/BPP for well-being
Monitor for variable decelerations (cord compression)
Assess for prolapsed cord

3. Medications

Antibiotics (GBS prophylaxis)
Corticosteroids if <34 weeks (lung maturity)
Tocolytics controversial (may be used <32 weeks)

2. Preterm Labor

Remember: "MONITOR"

Magnesium sulfate
Oxygen if needed
Nifedipine option
IV hydration
Terbutaline subQ
Observe contractions
Record fetal heart rate

Medications for Preterm Labor

Magnesium Sulfate

Loading: 4-6g IV over 20-30 min | Maintenance: 2-3g/hour

Monitor: DTRs, respiratory rate (>12), urine output (>30mL/hr)

⚡ Antidote: Calcium gluconate 10% 10mL IV

Terbutaline

0.25mg subQ q20min x 3 doses

Side effects: Tachycardia, tremors, hypokalemia

❌ Contraindicated >48-72 hours (cardiac risk)

Nifedipine

20mg PO loading, then 10-20mg q4-6h

Monitor: Blood pressure (hypotension risk)

⚠️ Caution with magnesium (potentiates)

Indomethacin

50mg PO/PR, then 25mg q6h

Limit: Use only <32 weeks, max 48 hours

❌ Closes ductus arteriosus

Fetal Fibronectin Test

Pre-test Requirements

NO vaginal exam in past 24 hours
NO intercourse in past 24 hours
NO vaginal ultrasound in past 24 hours

Interpretation:
Negative = 99% won't deliver in 2 weeks ✅
Positive = Only 20% will deliver ⚠️

3. Emergency Situations During Labor

Shoulder Dystocia

HELPERR Mnemonic - IMMEDIATE Actions

H - Call for Help
E - Evaluate for Episiotomy
L - Legs (McRoberts position - knees to chest)
P - Suprapubic Pressure (NOT fundal!)
E - Enter maneuvers (Woods screw)
R - Remove posterior arm
R - Roll to all fours

🚫 NEVER DO

Fundal pressure - This worsens impaction!

Umbilical Cord Prolapse

IMMEDIATE Action Sequence

Call for help - STAT cesarean
INSERT HAND - elevate presenting part OFF cord
Trendelenburg or knee-chest position
DO NOT attempt to replace cord
Cover exposed cord with warm saline gauze
Continuous fetal monitoring
Prepare for immediate cesarean

✓ Remember

Student nurses CAN perform emergency interventions to save lives!

Amniotic Fluid Embolism

Recognition Triad

Sudden respiratory distress
Cardiovascular collapse
DIC/Coagulopathy

Mortality Rate: 80% - IMMEDIATE action required!

4. Postpartum Hemorrhage (PPH)

NEW Definition

Blood loss >1000mL OR bleeding with signs/symptoms of hypovolemia within 24 hours

The 4 T's of PPH

Medication Sequence for Uterine Atony

Order	Medication	Dose	Contraindications
1st	Oxytocin (Pitocin)	10-40 units in 1L fluid	None
2nd	Methylergonovine (Methergine)	0.2mg IM	❌ Hypertension
3rd	Carboprost (Hemabate)	250mcg IM q15min (max 8)	❌ Asthma
4th	Misoprostol (Cytotec)	800-1000mcg rectally	None

"GRAND MULTIPARA" Risk Factors

Grand multipara
Rapid/prolonged labor
Amnionitis
Neonatal macrosomia
Distended bladder

Multiple gestation
Uterine overdistention
Labor augmentation
Tocolytics
Induction
Precipitous delivery
Amnionitis
Retained placenta
Abruption history

5. Postpartum Infections

Definition

Temperature 100.4°F (38°C) or higher on ANY 2 of first 10 days postpartum (excluding first 24 hours)

Endometritis Risk Factors - "LABOR CAMP"

LABOR CAMP

Long labor
Amnionitis during labor
Bacterial vaginosis
Operative delivery
Ruptured membranes >18hr

Chorioamnionitis
Anemia
Multiple vaginal exams
Poor prenatal care

REEDA Assessment for Wound Infections

R	Redness beyond incision edges
E	Edema of incision
E	Ecchymosis (unusual bruising)
D	Drainage (purulent, foul)
A	Approximation (edges separating)

Mastitis Management - "HEAT"

HEAT Protocol

Heat before feeding (helps milk flow)
Empty breast frequently (continue BF!)
Antibiotics x 10-14 days (dicloxacillin)
Tylenol/ibuprofen for comfort

Critical: CONTINUE BREASTFEEDING - it's safe for baby!

6. Thromboembolic Disorders

Virchow's Triad - All Present in Pregnancy!

DVT vs PE Recognition

Condition	Key Signs	Immediate Action
DVT	• Unilateral leg swelling • Calf pain with dorsiflexion • Warmth and erythema • LEFT leg most common	• DO NOT MASSAGE • Bed rest with elevation • Measure calves daily • Start anticoagulation
PE	• Sudden dyspnea • Sharp chest pain • Tachycardia/tachypnea • O2 sat <95% • "Sense of doom"	• High-flow O2 10L • HOB 45-60° • Call Rapid Response • Large bore IV • Prepare for ICU

⚠️ Remember

DVT can progress to PE in SECONDS - always assess for PE symptoms in DVT patients!

7. Postpartum Mood Disorders

Comparison Chart

Disorder	Incidence	Onset	Duration	Key Features	Management
Baby Blues	50-80%	Days 3-5	<2 weeks	Crying, mood swings	Support, reassurance
PPD	10-20%	Any time 1st year	>2 weeks	Can't function, no joy	Therapy, SSRIs
PP Psychosis	0.1-0.2%	First 2 weeks	Variable	Hallucinations, delusions	EMERGENCY - hospitalize

Postpartum Psychosis - IMMEDIATE Actions

Never leave alone with baby
Call psychiatry STAT
Likely needs admission
Remove potential weapons
Maintain calm environment
Document exact words/behaviors

Interactive Knowledge Check

Question 1: A woman at 35 weeks gestation reports a sudden gush of fluid. The fluid appears yellow-tinged. What is your PRIMARY concern?

Chorioamnionitis (infection)
Imminent delivery
Cord prolapse
Placental abruption

Question 2: A postpartum patient is bleeding heavily. Her fundus is boggy and displaced to the right. What is your FIRST action?

Call for help
Massage the fundus
Check vital signs
Increase IV oxytocin

Question 3: During delivery, the baby's head delivers but the shoulders do not follow. What should you NEVER do?

Apply suprapubic pressure
Apply fundal pressure
Call for help
Position mother in McRoberts

Question 4: A patient receiving magnesium sulfate for preterm labor has absent DTRs. What is your priority action?

Check serum magnesium level
Stop the magnesium infusion
Notify the physician
Administer calcium gluconate

Question 5: Which medication is contraindicated for a postpartum patient with asthma who is experiencing hemorrhage?

Oxytocin
Methylergonovine
Carboprost (Hemabate)
Misoprostol

Quiz Progress: 0/5

Quick Reference Summary

Emergency Phone Triage Rules

NEVER: Diagnose over phone, recommend medications, tell them to wait

ALWAYS: "Come to hospital for evaluation"

Priority Framework

Life-threatening emergencies (AFE, severe PPH)
Threats to maternal stability
Threats to fetal well-being
Pain/comfort (unless affecting VS)
Teaching needs

When You See These Words, Think:

• "Board-like abdomen" → Abruption
• "Turtle sign" → Shoulder dystocia
• "Ripping sensation" → Uterine rupture
• "Can't catch breath after delivery" → AFE or PE
• "Gush of fluid, baby won't come down" → Cord prolapse